May 28, 2010

Pathologist Consults for Transfusion Issues

Over the years, I have developed a list of situations for a hospital transfusion service for which I (or the on-call pathologist) should be notified and consult with the med tech in the "blood bank." Some of them are indeed mandatory but all of them generally are what I would described as deviations from the normal SOP. I use my judgment on whether or not to directly call clinicians, the O.R., or go up to the floor--but when I have done any of the aforementioned, my input and advice has always been well-received. Most of these are not emergency situations and encourage the techs to call us when it is practical even if it is in the middle of the night. From a practical standpoint, I have learned that communication the next morning or day is by someone who was not actually involved in the situation and is handing off a scribbled note or incomplete verbal communication. We (as pathologists) shouldn't underestimate our impact into patient care in unusual transfusion situations.

Request for emergency release of uncrossmatched RBCs. Although the blood needs to be out the door before I am reached, I want to know about this as soon as possible so I can speak to the clinicians and give them some reassurance and timeframes as more appropriate units are available (ABO- and then crossmatch-compatible).

Adverse reactions to transfusion. This is one of those mandatory situations and one in which we always issue a written report or note. Also includes suspected transfusion-related acute lung injury (TRALI) and transfusion-transmitted infections (e.g., "look-back" and subsequent donor testing).

High utilization of blood components. This is the massive transfusion situation. The anesthesiologists are fairly well-aware of the physiological sequelae of massive transfusion, so I mainly call them to get an idea of how the patient is doing so I can communicate to the blood bank on how many more units may be needed, our inventory, switching blood types, and whether or not an emergency run is needed to replenish our supply.

Requests for specialized blood components. This incorporates requests for washed RBCs, CMV-seronegative components, etc. It is amazing how often such requests are made "because that is what we did in residency." Most of these are not necessary and it provides me a "teaching moment."

Feto-maternal hemorrhage. The blood bank techs interpret the Kleihauer-Betke stain for the purpose of determining the appropriate dose of RhoGam and are not comfortable doing this. We score adequately on proficiency testing but I think it touches the patient too much for them. Anyway, I just like to know about these situations.

Serological problems. This includes positive DATs, newly discovered alloantibodies and autoantibodies, ABO discrepancies, etc. This constitutes most of the day-to-day consults and mostly consists of reviewing the work-up. I also approve send-outs to the Red Cross for additional work-ups and sign-off on the reports as they come back. I just like knowing about these too and occasionally talking to clinicians if the work-up is delaying a patient receiving blood.

Possibly inappropriate utilization of blood components. This may be an emerging area for consultation but will likely be at a higher order level rather than at the direct patient care level. Techs don't like functioning as gatekeepers and telling surgeons "no" so I encourage them to call me if something doesn't smell or sound right.

Hope you find this of help. Your comments and questions are welcome. Are there situations that you confront where a pathologist consultation is helpful?